Elsevier

Ophthalmology

Volume 126, Issue 11, November 2019, Pages 1527-1532
Ophthalmology

Original Article
Quantitative Ultra-Widefield Angiography and Diabetic Retinopathy Severity: An Assessment of Panretinal Leakage Index, Ischemic Index and Microaneurysm Count

https://doi.org/10.1016/j.ophtha.2019.05.034Get rights and content

Purpose

To investigate the relationship between the diabetic retinopathy (DR) severity and quantitative ultra-widefield angiographic metrics, including leakage index, ischemic index, and microaneurysm count.

Design

Retrospective image analysis study.

Methods

Eyes with DR that had undergone ultra-widefield fluorescein angiography (UWFA) with associated color photography were identified. All eyes were laser-naive and had not received any intravitreal pharmacotherapy within 6 months of UWFA. Each eye was graded for DR severity. Quantitative angiographic parameters were evaluated with a semiautomated analysis platform with expert reader correction, as needed. Angiographic parameters included panretinal leakage index, ischemic index, and microaneurysm count. Clinical characteristics analyzed included age, gender, race, hemoglobin A1C level, hypertension, systolic blood pressure, diastolic blood pressure, and smoking history.

Main Outcome Measures

Association of DR severity with panretinal leakage index, ischemic index, and microaneurysm count.

Results

Three hundred thirty-nine eyes were included with mean age of 62±13 years. Forty-two percent of eyes were from women and 57.5% were from men. Distribution of DR severity was as follows: mild NPDR in 11.2%, moderate NPDR in 23.9%, severe NPDR in 40.1%, and PDR with 24.8%. Panretinal leakage index [mild NPDR (mean = 0.51%), moderate NPDR mean = 1.20%, severe NPDR (mean = 2.75%), and PDR (mean = 5.84%); P<2×10–16], panretinal ischemic index [mild NPDR (mean = 0.95%, moderate NPDR (mean = 1.37%), severe NPDR (mean = 2.80%), and PDR (mean = 9.53%); P<2×10–16], and panretinal microaneurysm count [mild NPDR (mean = 36), moderate NPDR (mean = 129), severe NPDR (mean = 203), and PDR (mean = 254); P<5×10–7] were strongly associated with DR severity. Multivariate analysis demonstrated that ischemic index and leakage index were the parameters associated most strongly with level of DR severity.

Conclusions

Panretinal leakage index, panretinal ischemic index, and panretinal microaneurysm count are associated with DR severity. Additional research is needed to understand the clinical implications of these parameters related to progression risk, prognosis, and implications for therapeutic response.

Section snippets

Methods

This retrospective image analysis study was approved by the Cleveland Clinic Investigational Review Board. The study adhered to the tenants of the Declaration of Helsinki. Informed consent was not required for this retrospective study. Images from patients with DR who had undergone UWFA were identified. All participants underwent UWFA imaging with either the Optos 200Tx (Optos, Dunfermline, United Kingdom) or California (Optos) systems. Ultra-widefield fundus photography and UWFA for each

Results

A total of 339 eyes (175 right eyes, 164 left eyes) from 198 patients with DR were included in the study. Demographic and baseline characteristics are presented in Table 1. Of all eyes, 144 (42.5%) were from women and 195 (57.5%) were from men, with a mean age of 62±13 years. The mean visual acuity was 20/48. Hemoglobin A1C levels were available for 158 eyes with a mean of 8.1% (standard deviation [SD], 2.0%). Diabetic retinopathy severity included 38 eyes (SD, 11.2%) with mild nonproliferative

Discussion

The present study investigated the relationship between the severity of DR and quantitative angiographic features on UWFA. As DR severity increased, the panretinal leakage index (P = 2 × 10–16), panretinal ischemic index (P = 2 × 10–16), and panretinal MA count (P = 5 × 10–7) increased significantly in each category. Clinical characteristics, such as smoking, gender, race, and HbA1C level, also were linked with DR severity, consistent with previous studies.12, 13, 14, 15, 16 These results also

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Financial Disclosure(s): The author(s) have made the following disclosure(s): J.P.E.: Consultant – Leica (Wetzlar, Germany), Zeiss (Oberkochen, Germany), Santen (Osaka, Japan), Novartis (Basel, Switzerland), Aerpio, (Blue Ash, Ohio), Genentech (San Francisco, CA), Thrombogenics (Leuven, Belgium), Regeneron (Tarrytown, NY), Alcon (Fort Worth, TX), Allegro (San Juan Capistrano, CA); Financial support – Thrombogenics, Genentech, Thrombogenics, Regeneron, Alcon, Aerpio, Novartis; Patent – Leica.

A.B.: Consultant -- Genentech; S.S.: Consultant – Eyepoint (Watertown, MA).

S.K.S.: Consultant – Bausch & Lomb (Rochester, NY), Zeiss, Santen; Financial support – Allergan; Patent - Leica.

Supported by the National Eye Institute, National Institutes of Health, Bethesda, Maryland (grant no.: K23-EY022947-01A1 [J.P.E.]); and Research to Prevent Blindness, Inc., New York, New York (to the Cole Eye Institute). The funding organizations had no role in the design or conduct of this research.

HUMAN SUBJECTS: Human subjects were included in this study. The human ethics committees at the Cleveland Clinic approved the study. All research adhered to the tenets of the Declaration of Helsinki. Informed consent was not required for this retrospective study.

No animal subjects were included in this study.

Author Contributions:

Conception and design: Ehlers

Analysis and interpretation: Ehlers, Jiang, Boss, Hu, Figueiredo, Babiuch, Talcott, Sharma, Hach, Le, Rogozinski, Lunasco, Reese, Srivastava

Data collection: Ehlers, Jiang, Boss, Hu, Figueiredo, Babiuch, Talcott, Sharma, Hach, Le, Rogozinski, Lunasco, Reese, Srivastava

Obtained funding: Ehlers, Srivastava

Overall responsibility: Ehlers, Jiang, Boss, Hu, Figueiredo, Babiuch, Talcott, Sharma, Hach, Le, Rogozinski, Lunasco, Reese, Srivastava

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© 2019 by the American Academy of Ophthalmology